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Benign paroxysmal positional vertigo (BPPV) can be quite a debilitating condition for patient it effects. What are the two maneuvers that are used at the bedside for this condition and how do they differ?

You have a patient in the ED with an aortic dissection and are managing them while awaiting the cardiovascular surgeon to arrive.

What are the two most important things to control?

How do you go about doing that?

Answer

The main aims of acute medical management of aortic dissections are to decrease the rate of left ventricular contraction and decrease the velocity of the contraction, which will overall decrease the shear stress at the site of the tear and slow progression.

Start with intravenous beta-blockade and titrate to a heart rate of 60 betas/minute

If systolic blood pressure is > 120 mmHg after successful beta-blockade, then add a vasodilator or afterload reducer.

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121(13):e266-369. [pubmed]

Definition – muscular ring surrounding the major duodenal papilla at the 2nd portion of the duodenum.

Clinical Significance – the sphincter of Oddi allows for drainage of the biliary and pancreatic systems and dysfunction (mainly spasming) can can cause pancreatitis. It is in a constant state of contraction unless relaxed by cholesytokinin released by vasoactive intestinal peptide. Opioids, specifically morphine, has been shown to increase the risk of sphincter of Oddi dysfunction.

History – Named after Ruggero Ferdinando Antonio Guiseppe Vincenzo Oddi (1864-1913), who was an Italian physiologist and anatomist from Perugia. He spent is formative years studying medicine at Perugia, Bologna, and Florence and was appointed head of the Physiology Institute at the University of Genoa in 1894. In 1887, at only 23 years old, he described his eponymous structure in his paper “D’une disposition a sphincter speciale de l’ouverture du canal choledoque”. His career, unfortunately, was derailed and cut short due to opioid addiction many believe was as a result of using morphine derivatives to study dysfunction of the sphincter.

Definition – portion of the dorsal duct distal to the dorsal-ventral fusion point during embryonic development

Clinical Significance – 85% of the population have a single, main pancreatic duct and 15% can have an accessory duct that either drains into the duodenum by a separate ampulla (2/3), or drains into the main duct (1/3). These anatomical variants need to be explored prior to instrumentation for pancreatic pathology as it can occur with pancreas divisum, which makes the accessory duct the principle drainage duct for the pancreas.

History – Named after Giovanni Domenico Santorini (1681-1737), who was an Italian anatomist and son of an apothecary. He spent his formative years studying medicine throughout Bologna, Padua, and Pisa, where he received his medical doctorate in 1701. He performed anatomical dissection demonstration in Venice for 23 years, during which he published his most famous work entitled Observationes Anatomicae. This work was considered one of the most detailed and important anatomical texts of the time and gave way to descriptions of twelve different anatomic eponyms accredited to Santorini.

The term “celiac” has Latin and Greek roots as Aretaeus of Cappadocia named this disease in the 1st century AD “koiliakos” meaning abdomen/abdominal in patients with chronic diarrhea. The first modern medical description of the disease was in 1888 by Samuel Gee in an paper entitled “On the Coeliac Affection”. The specific medical term for Celiac Disease is “gluten-sensitive enteropathy”. It was still relatively unexplained until Willem Dicke, a Dutch pediatrician, noted improvement in his patient’s abdominal symptoms during bread and grain shortages of World War II.

Epidemiology

Primarily in northern European white

Prevalence is widely variable due to differing rates and types of population screening throughout the world

Pathophysiology

High association with genetic predisposition to gluten sensitivity, specifically HLA-DQ2 and/or DQ8, and because of these genetic changes, serum autoantibodies are produced that attack the endomysium of the enterocytes of the small bowel.

Signs and Symptoms

Originally thought to be a disease of infancy, it is being
diagnosed later and later in life, with adults first being diagnosed as late as
the fifth decade. Often, this is in the
setting of failure to thrive in an infant.